The authors of the NEJM article in favor of a three-year MD assert that the shortened program will lead to a reduction in student debt burden.  I believe this assertion is incorrect.

In fact, a three-year training program will be more attractive to students pondering a career in medicine, so the demand for medical training will rise.  When demand for something rises, but supply remains fixed, the cost goes up, not down.  There might be a temporary period where the three-year MD is less costly, but over the long run prices will equilibrate according to supply and demand. 

One might say that stewards of public institutions will commit to keeping per-year tuition low, and so the actual cost of a three-year program at public institutions will remain low compared to the four-year program.  But this, too, misses the larger picture.  We have a lot of private institutions of education in this country, which is another way of saying that market forces rather the decisions by public administrators are what largely determine the average price of education.  

To see why this is the case, it may be helpful to partially sketch out the mechanism of price equilibration in our mixed public-private system.  As a result of price controls at public institutions, the capacity of medical school classes at public schools will grow more slowly than the capacity of classes at private institutions that do not face the same revenue constraints.  Over the long term, the number of such spots will decline in comparison to the number of spots at private schools, and there will be increased competition for the relatively small number of spots available at public schools where tuition is controlled.  Ultimately, the overall debt burden will increase as more students attend expensive private institutions.

The outcome might be different if there were very few private institutions and if higher education were provided largely by the state, as it is in many other countries.  But in our country we have a very large private market in education.  As a consequence, the state is largely unable to set prices, except by acting through the channels of supply and demand. 

Adding a three year option only works if there are robust assessment measures, clear milestones, strong career advising and motivated students.  This option is consistent with our Carnegie recommendation to standardize on learning outcomes and individualize the learning process. 

Outcomes from three year programs are identical to that of four year programs.  Thus, the fourth year should offer other opportunities that might entice our students to continue through the four years (such as the Pathways to Discovery Program, joint masters degree programs, and other elective opportunities). Currently, 40% of our students take longer than four years so I don't anticipate that the three year option will be a large pathway. But, it will be an important pathway because it demonstrates our commitment to personalized education and flexible programs.

I think increasing flexibility by shortening to a 3-year program could be a great option for students selecting a career in one of the core clerkship disciplines, but would be challenging for those interested in a specialty not otherwise represented. As discussed in the NEJM papers, this would only be realistic for students continuing at the same institution for residency (or at a different institution also offering a 3-year program).

If the larger goal in creating the 3-year curriculum is to shorten the total time before beginning practice (and reduced number of years accruing debt), praticularly in fields that have very long training processes (i.e. 6-7 year residencies with 1-2 year fellowships to follow), will the 3-year option actually have the desired impact? Would the directors of those training programs at our institution welcome these students into a coveted position without time to do research or additional study? I worry that the program would only shorten the process for students choosing a more general discipline, which would have a lower impact on the larger goal.

I think it would be critical to involve UCSF residency program directors in the discussion to ensure they will support excellent students in this pathway. They are key stakeholders who will influence the success (or failure) of the short track.

My other comments/questions are more logistical--

A seamless process for converting to a 4-year program if a student's goals or readiness change would be critical. Logistically, it sounds quite challenging to create a personalized compressed program that remains flexible enough to accommodate dynamic change. At what timepoints would the change be possible? Would the converted student rejoin the 4-year curriculum "off-cycle"? If they have a more compressed "pre-clinical" curriculum, would faculty have to teach adapted courses twice a year? This may be acceptable to core SOM education faculty, but what about all of the additional apprenticeship experience faculty? How would the timing of USMLE Step 1 and 2 fit in with a 3-year model?

I am not convinced by the argument for a purely 3 year curriculum.  As has been mentioned in prior comments, the critical advancement that must be acheived before this takes hold is a robust, valid and flexible assessment process.  The current state of assessment is not up to the task as subjective assessments are not completed with adequate care and objective assessments are limited to medical knowledge domains.

I strongly advocate a flexibly timed curriculum, that allows learners to progress at their own rate and develop skills that they value.  The logistical challenges of this approach are monumental and would require a deep embrace of competency and objective based education (as opposed to simple mapping of objectives to pre-existing material).

The current siloing of the pre-clinical and clinical curricula is a major driver of the length of medical school.  The content that medical students learn in lecture halls could easily be encorporated into the clinic (and might reduce student temptation to volunteer for scutwork that does not impact their learning but may bolster evaluations).

I support the flexibility of 3- or 5-year options for students, depending on their interests and their demonstrated expertise.  There are opportunities to build early clinical experiences into the curriculum, allowing some students to identify and pursue early differentiation into a subfield.  There is an additional opportunity for a didactic, and potentially interprofessional, summer quarter.   Some of the costs of education are fixed costs - should the physical therapy students be the sole occupants of fixed cost university classrooms during the summer?  Although many medical students participate in educational experiences during the summer quarter, the UME curriculum schedule could be altered from the current undergraduate model to a graduate level, year-round educational model. 

Overall, I am in favor of the idea of an individualized pathway in medical education.  Lengthier pathways (i.e., 5+ years) are already in place somewhat, as students will often extend their UME years by taking a year of research, a year to do a masters degree, etc.  I remember several members of my medical school class at UCSF "splitting" their MS2 year into two years to enable more time to focus on the difficult academics. (Not sure if that is still an option here . . .?). 

Extension of medical school is, of course, easier than shortening it.  As reiteratedin the comments below, regular, thorough assessments and close tracking of students needs to occur for this to work and ensure we are producing learners prepared for intern year, academically, psychologically and professionally.  I also agree with Nina that this is much more likely to work for those entering less competitive specialties and planning to stay at their home institutions. 

Ways to compress the curriculum as it stands now, could involve eliminating the summer between 1st and 2nd years, decreasing the length of various core rotations (for example, I know some medical schools only have a 3 week pediatrics rotation) and eliminating fourth year electives.  The question is what curriculum changes do you apply universally to all medical students and what to simply the "fast-trackers"? The more curriculum pathways, the more money, admin time and faculty involvement needed, which could be problematic.

I do find the idea exciting, though!

Interesting conversation. I recognize the economic pressures and why a 3-year curriculum would be valuable but I would hate to see clinical experience shortchanged. The preclinical curriculum is a carefully crafted program - clinical experience is much harder to control, sinceit depends to a great extent on which patients happen to come in when a student is on each rotation. I recognize that thre are important competencies that can be learned from ANY patient but there are also some very special experiences that come only with certain, special patients, and it is really hard to predict and program for these. Cutting clincal time even more makes it less and less likely that a student wl encounter these highly formative experiences.

I have very much enjoyed the back and forth of this debate, and see great arguments on both sides. One unorthodox idea along these lines is why does medical school need to be set to a year requirement? Whether that requirement be 3-years or 4-years? If, as Dr. Irby and Dr. Laponis pointed out so well, if there are transparent, well delineated competencies, a very motivated student should be able to travel through the currciulum at a speed that is befitting of their goals, aspirations, temperment, and abilities. 

I think a 3-year or shortened medical school is more feasible now than ever. As many have pointed out, Duke has essentially been doing this for many years. Ohio State operates a "self-directed" track in which students do the majority of their learning on their own. As online learning tools improve, and on-line learning gains more acceptance, the ability to direct one's own learning, and to progress at variable speeds will be far greater.

On the other hand, while I think this is an interesting question, I can already poke many holes in my own arguments, many of which have been addressed in others comments. Being a medical resident, I know very little about the organizational side of medical education, and I can see how something like this could pose some impressive logistical obsticles. Scheduling exams, clinical rotations, and graduation ceremonies would be quite the challenge. Additionally, I am proud of the steps that the ACGME have taken to ensure duty hour restrictions in an attempt to improve resident wellness, health, and patient safety. Allowing medical students to barrel through the curriculum "at their own risk," could present many wellness issues. And lastly, something I don't recall seeing mentioned, the camraderie of the medical school experience would take quite a blow if everyone was taking the curriculum on individually. Having completed medical school recently myself, I look back on my time fondly, mostly for the experiences shared with others, tackling obstacles as a united class.

There were certainly times in medical school when I felt the curriculum could have made better use of my time, or thing could have been more condensed. But would I have lost some of the structure? Or would I have lost the supportive and caring enviroment in which I was able to learn? Or perhaps I would have lost the camraderie, the piece I will remember with the most nostalgia? A three-year curriculum has potential cost benefits, and benefits of time efficiency, but what would we be giving up?